Orbit The International Journal on Orbital Disorders, Oculoplastic and Lacrimal Surgery ISSN: 0167-6830 (Print) 1744-5108 (Online) Journal homepage: http://www.tandfonline.com/loi/iorb20 A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis Marvi Cheema, Kelsey Roelofs, Imran Jivraj, Robert West, Steve Rasmussen & Audrey Chan To cite this article: Marvi Cheema, Kelsey Roelofs, Imran Jivraj, Robert West, Steve Rasmussen & Audrey Chan (2017): A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis, Orbit, DOI: 10.1080/01676830.2017.1383457 To link to this article: http://dx.doi.org/10.1080/01676830.2017.1383457 Published online: 20 Oct 2017. Submit your article to this journal Article views: 2 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iorb20 Download by: [University of Florida] Date: 27 October 2017, At: 09:58 ORBIT https://doi.org/10.1080/01676830.2017.1383457 CASE REPORT A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis Marvi Cheemaa, Kelsey Roelofsa, Imran Jivraja, Robert Westb, Steve Rasmussenc,d, and Audrey Chana Department of Ophthalmology, University of Alberta, Edmonton, Canada; bDepartment of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada; cDepartment of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada; d Department of Laboratory Medicine and Pathology, University of British Columbia, Vancouver, Canada Downloaded by [University of Florida] at 09:58 27 October 2017 a ABSTRACT ARTICLE HISTORY The differential diagnosis for acute orbital inflammation is broad. We report a case of granulomatous orbital inflammation due to high-pressure oil injury to the orbit presenting as an atypical orbital cellulitis. Here we review the presentation and treatment of orbital inflammation from oil. Received 1 December 2016 Accepted 19 September 2017 KEYWORDS Grease; lipogranulomatous inflammation; orbital cellulitis; orbital inflammation Case A 65-year old man presented to the ophthalmology clinic with a 6-day history of worsening left periorbital swelling and diplopia. On examination, he was afebrile and comfortable. Visual acuities were 20/20 OD and 20/60 OS and optic nerve function was intact bilaterally. Extensive left sided periorbital edema was evident. Ductions were severely limited. Slit lamp examination revealed chemosis and conjunctival injection OS. Exophthalmometry revealed 8 mm of proptosis. Intraocular examination was unremarkable. A contrast-enhanced CT scan of the orbits showed extensive preseptal and intraconal inflammation with a prominent collection adjacent to the left optic nerve, and numerous hypodense loculated spaces within the orbit. (Figure 1). The patient was diagnosed with atypical orbital cellulitis and treated with broad spectrum intravenous antibiotics. Given clinical worsening over the next 48 hours, an orbital biopsy was arranged. Intraoperatively, firm yellow–white material was found throughout the orbicularis and orbital fat; the abnormal tissue was debrided and specimens were submitted for culture and pathology. Upon histopathologic examination, a florid lipogranulomatous response was noted. Granulomas, composed primarily of histiocytes and a few multinucleated giant cells, were identified surrounding multiple optically clear spaces. (Figure 2). The patient had earlier denied any history of trauma, however, upon further questioning, recalled being struck by a pressurized jet of hydraulic oil while repairing his tractor 3 weeks prior to presentation. He had been asymptomatic in the interim. After orbital biopsy and debridement, he received 1 g of IV solumedrol for 3 days followed by a 2-week oral prednisone taper. The patient responded rapidly to treatment with preserved visual function and substantially improved periorbital swelling, motility, and proptosis. Discussion The differential diagnosis for acute orbital inflammation is broad. A complete history should encompass the onset and duration of pain and orbital symptoms, associated trauma or foreign body exposure, the presence of fever and constitutional symptoms, previously diagnosed sinusitis, thyroid disease, vasculitic entities, immunosuppressive conditions or medications, malignancy, and a thorough review of symptoms.1 Our patient denied antecedent skin trauma, sinusitis, or significant pain. He was afebrile and laboratory studies showed an absence of leukocytosis. There was no skin wound or obvious entry site for a foreign body. CT identified preseptal and intraconal inflammation and atypical hypodense loculated spaces which raised CONTACT Audrey Chan firstname.lastname@example.org Department of Ophthalmology and Visual Sciences, University of Alberta, Royal Alexandra Hospital, 2319 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Edmonton, Canada. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iorb. © 2017 Taylor & Francis 2 M. CHEEMA ET AL. Downloaded by [University of Florida] at 09:58 27 October 2017 Figure 1. Contrast enhanced CT images of the orbits with axial, coronal, and sagittal views demonstrating (a) Significant axial proptosis and extensive preseptal and intraconal inflammation with a localized collection adjacent to the optic nerve; (b) and (c) Numerous hypodense loculated spaces within the orbit. Figure 2. (a) Florid granulomatous foreign body inflammatory reaction associated with abundant optically clear spaces (50X); (b) and (c) Closer look at granulomas and clear spaces (100X); and (d) Large oil droplet surrounded by granulomatous inflammation including numerous histiocytes and a few multinucleated giant cells. concern for gas-forming anaerobic organisms. Orbital biopsy revealed evidence of lipogranulomatous inflammation with vacuolated spaces compatible with oil, rather than gas. Our patient’s later recollection of antecedent injury with pressurized hydraulic oil confirmed the diagnosis. In our case the oil likely entered the orbit via the conjunctival fornix, and inflammation at the site obscured the evidence of minor trauma. To our knowledge, this is the seventh reported case of grease gun injury resulting in orbital lipogranulomatous inflammation.2–6 Patients have presented to care immediately following injury4 or, in the case of an eyelid lipogranuloma following hydraulic oil injury, up to 1 year later.7 Grease gun trauma may cause penetrating foreign body injuries without a significant or noticeable entry wound, especially when the initial wound has healed over in later presentations.4 Similar presentations have been reported with silicone oil after vitreoretinal surgery, following paraffin ointment use in lacrimal and endoscopic sinus surgery and following cosmetic hyaluronic acid, poly-L-lactic acid, and polyalkylimide fillers.8–14 Injections at sites distant from the orbit, such as the nasolabial folds, may lead to periorbital inflammation after migration.14 Presenting symptoms include pain, orbital swelling, decreased vision and diplopia, and visual acuity at presentation ranges from 20/40 to light perception.2–6 On orbital imaging, grease appears as cysts or hypodense masses within ORBIT subcutaneous tissues or disruption of fat. 3,5,6 During surgical exploration, extrusion of grease from orbital tissues has been described.2–6 The histopathological diagnosis must be distinguished from liposarcoma which may share pathological features.15 Management of granulomatous orbital inflammation from exogenous oil varies from immediate surgical exploration and thorough removal of oil8 to close observation of asymptomatic patients.5 Our case demonstrates that atypical features should prompt an orbital biopsy and surgical debridement. If not adequately debrided, it is possible that residual foreign material could elicit a similar inflammatory episode in the future once corticosteroids have been tapered. Downloaded by [University of Florida] at 09:58 27 October 2017 Conclusion Our case emphasizes the importance of attention to atypical features in determining the etiology of an orbital inflammatory process. In the presence of such features, or without satisfactory response to appropriate empiric antibiotics, there should be a low threshold for obtaining orbital biopsy for microbiologic and pathologic studies. We advocate that surgical debridement is a key step in the management of cases presenting similarly to ours, and suggest that adjuvant corticosteroid therapy be considered. Disclosure statement The authors have no proprietary or financial interests to disclose. Funding This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. References 1. 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